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<html lang="en">
<head>
    <meta charset="UTF-8">
    <title>恶魔狂想曲_至尊VIP</title>
    <link rel="stylesheet" href="__PUBLIC__/emvip/css/reset.css" />
    <link rel="stylesheet" href="__PUBLIC__/emvip/css/common.css" />
</head>
<body>
<div class="wrapper">
    <div class="banner"></div>
    <div class="vip_content">
        <h3>至尊VIP信息填写</h3>
        <span class="text">亲爱的玩家：请您认真的填写以下至尊VIP信息，我们将会在您提交成功后，1个工作日内完成验证并且电话联系您。</span>
        <ul>
            <li>
                <label for="id"><em class="red">*</em>游戏ID:</label><input type="text" id="id" name="id" placeholder="游戏角色数字ID" />
            </li>
            <li>
                <label for="nickname"><em class="red">*</em>角色昵称:</label><input type="text" id="nickname" name="nickname" placeholder="游戏角色昵称" />
            </li>
            <li>
                <label for="vip_level"><em class="red">*</em>VIP等级:</label><input type="text" id="vip_level" name="vip_level" placeholder="游戏VIP等级" />
            </li>
            <li>
                <label for="name"><em class="red">*</em>姓名:</label><input type="text" id="name" name="name" placeholder="请填写姓名" />
            </li>
            <li>
                <label for="birth">出生年月:</label><input type="text" id="birth" name="birth" onclick="WdatePicker();" placeholder="请填写日期" />
            </li>
            <li>
                <label for="qq"><em class="red">*</em>QQ:</label><input type="text" id="qq" name="qq" placeholder="请填写QQ" />
            </li>
            <li>
                <label for="occupation">职业:</label><input type="text" id="occupation" name="occupation" placeholder="请填写职业" />
            </li>
            <li class="last_d">
                <label for="tel"><em class="red">*</em>手机:</label>
                <input type="text" id="tel" name="tel" placeholder="请填写手机号码" />
                <button id="fsyzm" class="fsyzm"></button>
                <input type="text" id="send_num" name="send_num" placeholder="请填写验证码" />
            </li>
            <li class="last_d">
                <label for="address"><em class="red">*</em>地址:</label><input type="text" id="address" name="address" placeholder="请填写详细地址" />
            </li>
        </ul>
        <div class="btn">
            <input type="hidden" id="message_code" name="vkey" />
            <button type="button" class="tj"></button>
            <button type="reset" class="qx"></button>
        </div>
    </div>
</div>
<script src="__PUBLIC__/emvip/js/jquery-1.11.2.min.js"></script>
<script src="__PUBLIC__/emvip/js/common.js"></script>
<script src="__PUBLIC__/emvip/My97DatePicker/WdatePicker.js"></script>
</body>
</html>